Promoting Health and Productivity for Depressed Patients in the Workplace

OBJECTIVE
To discuss the impact of major disease states, including depression, in the loss of productivity in the workplace and how integration of health care can decrease cost to employers.


SUMMARY
The majority of costs associated with depressive illness can be traced to lost productivity, and the employer, therefore, bears most of the economic burden. Efforts to improve employee health and productivity have been hampered by the compartmentalization of medical costs, pharmacy costs, behavioral health costs, and productivity measures. This situation can be rectified by "busting" these silos and promoting a reintegration of prospective costs and parties. Health risk assessments enable employers to identify illnesses that are suitable targets for integrated health and productivity management programs. In the case of depression, employers can act proactively to identify employees at risk, working to minimize risk factors such as stress before these individuals become heavy utilizers of company resources. For employees who are currently depressed, recent research evidence has demonstrated that pharmacotherapy can have a dramatic and positive effect on lost productivity, absenteeism, and presenteeism. The selection of antidepressants and subsequent follow-up must be improved, however, if the benefits of pharmacotherapy are to be optimized.


CONCLUSION
Understanding the linkage of disease management and productivity in the workplace can result in dramatic decreases in absenteeism and presenteeism and increased cost savings to the employers.

D e p ression is one of the leading causes of disability in the United States, resulting in estimated medical costs of $26.1 billion annually. 1 I n d i rect costs are even higher, with more than $50 billion attributed to lost productivity and absenteeism among depressed employees. 2 The ultimate payer of these costs is the employer n o t the health plan since the majority of these costs are not incurred within the health care systems but in the workplace. Health care expenditures re p resent the fastest g rowing costs among employee benefits, but lost labor costs are much gre a t e r. In the long run, there f o re, the primary objective of managing depression should be to create a new value pro p o s i t i o n by examining the impact of health status-and cost-upon work p ro d u c t i v i t y.
The relationship of health status to employee productivity is vital to understand. In the coming years, the workforce will actually be shrinking so employers will need to keep their employees healthy if productivity is to be optimized. If depre s s e d patients continue to wind up on disability, the predicted decline in skilled, middle-aged employees will result in a serious deficit in the workforce, making it very difficult to sustain a competitive e n t e r p r i s e .

■ ■ Integration of Health Management
In order to better appreciate the impact of health upon p ro d u c t i v i t y, we will need to stop thinking of people (or employees) as diagnoses or disease entities. A total health measure must be c reated and quantified, and the focus has now shifted to measuring f u n c t i o n a l i t y. This can only be achieved by integrating several key activities (Table 1). For example, a thorough health risk assessment is essential in order to identify potential (or existing, but as yet undetected) cases of disease and ultimately avoid some or all of the direct and indirect costs that will eventually occur if no i n t e rvention is implemented. A health risk assessment also enables employers and health plans to target chronic illnesses for wellness and promotion activities to reduce the total disease b u rden. These programs may not be effective for all conditions so thought must be given to prioritizing disease states that may actually be significantly influenced by decreased risk (e.g., obesity, diabetes, and depression). After prevention, the focus shifts to disease management since we will never be able to eradicate all illnesses. The prevalence and severity of some chronic conditions will almost certainly rise in the coming years in spite of all eff o rts, as the workforce continues to age. The next link in this integrated chain then becomes disability management. While most companies continue to re g a rd disease management and disability management as 2 diff e re n t entities with distinct data sets and processes, they should really be analyzed and handled together. Fort u n a t e l y, this situation is i m p roving in the corporate world as companies such as United Technology begin to integrate these activities.

Integrated Health Management Requires Linking Several Key Activities
The final piece of integrated health care management can also be viewed as the sum total of the process. It is called "health and p roductivity management" (HPM), and it involves the integration of data and services specific to all other activities. HPM re q u i re s the deconstruction of these other "silos" or "stovepipes" so that corporations can analyze outcomes from a broader perspective than is currently possible. It is only through this level of integration that one can rapidly and accurately quantify medical cost off s e t s , d e c reased hospitalizations, and, most import a n t l y, improved work p e rf o rm a n c e .
The integration and reconfiguration of employee health and p roductivity has also led to the identification of the importance of o rganizational health and culture. For many employers, this is a f o reign term but it can have a major influence upon overall health. The term "organizational health and culture" re p resents an enhanced understanding of how the work environment can impact health status and functioning. Organizational health and c u l t u re is embodied in the apparent values of the workplace, the way employees interact, the means by which information is t r a n s m i t t e d , and how work is ultimately accomplished.
The success of health promotion and disease management p rograms will depend essentially on the culture in which these activities take place. For example, one needs to ascertain if upper management genuinely supports HPM activities and whether or not they are truly willing to invest in employees' health. For the f u t u re, it has become clear that employers must believe that employees are the corporation' s greatest asset and invest in HPM a c c o rdingly if they are to remain a viable enterprise.

■■ Specific Steps
T h e re are many steps involved in the integration of these activities. Busting the silos is a requisite if data is to be shared and used e ff e c t i v e l y. In the current situation, departmental incentives are typically to shift costs from one silo to the next (e.g., move employees f rom disability to workers compensation, turning a medical claim into a disability claim), which is of no economic benefit to the company overall. Once data is shared, it is then viewed within the context of the company' s own demographics. Cost stru c t u res, risk profiles, and other demographics will vary g reatly among corporations and in diff e rent regions of the c o u n t ry . A company' s specific demographics will often dictate w h e re in the HPM system the health dollars should be invested (e.g., health promotion versus disease management).
A diff e rent philosophical approach may also be necessary to integrate disease prevention with disease management. For instance, some health policy experts believe that the pre v i o u s focus upon heavy utilizers in a health care system is misguided. While it is true that 20% of a beneficiary pool will be re s p o n s i b l e for generating roughly 80% of the medical costs, the real challenge is to identify individuals in the remaining 80% of the population who are at increased risk for becoming heavy utilizers. 3 The goal is to keep these employees healthy well into the future. If the e n t i re eff o rt is directed toward controlling medical costs, the system, the employer, and the company are doomed to failure . The current demographics are not in the employers' favor. Technology and associated costs are working against them as well.
A final component to consider is how the re t u rn on these investments will be measured. Conservative estimates suggest that nonmedical costs are at least twice as high as direct medical e x p e n d i t u re s . 4 H i s t o r i c a l l y, employers have only been concern e d with the latter. If and when mechanisms are implemented to m e a s u re the success of HPM activities, it will become evident that the lost productivity costs should be the biggest target for employer i n t e rventions. Only then will employers genuinely begin to make employee health an explicit part of their business.

■■ Employers' Perspective
In an effort to characterize the attitudes and beliefs of administrators, the Institute for Health and Productivity Management conducted a cross-sectional survey in 2002 of corporate medical d i rectors, benefits directors, human re s o u rces directors, and associated wellness personnel. Their survey was designed to quantify the perceived medical reasons underlying employee absenteeism and lost productivity ( Table 2). The results appeare d

Promoting Health and Productivity for Depressed Patients in the Workplace
to reflect a wide variety of corporate backgrounds and experiences. The corporate survey revealed, for instance, that musculoskeletal conditions were believed to be the leading cause of absenteeism. This may be due to antiquated perceptions about the amount of physical labor currently perf o rmed in the workplace, but it may also reflect an increase in the prevalence of osteoarthritis, as one may come to expect from an aging population. Mental health was the #2 reason listed for absenteeism and pregnancy was third , though that is generally considered to be a short -t e rm disability as opposed to a chronic illness. Other conditions that were also identified with high absenteeism rates were re s p i r a t o ry conditions (e.g., allergies, chronic obstructive pulmonary disease, and asthma), g a s t rointestinal (GI) problems, and cardiovascular illness. The other question on the survey asked participants to rank the leading causes for lost productivity or "presenteeism," as it is now commonly known. The response of administrators provided additional testimony to the enormous impact that depression has on the workplace (Table 3). Presenteeism is believed to be a much bigger economic factor than absenteeism, in general, and in the s u rv e y, mental health was the leading reason listed for decreased p e rf o rmance. Depression, specifically, was commonly cited, suggesting that depressed employees will often show up for work but they're "not really there," or at least are not fully pro d u c t i v e . Musculoskeletal problems were perceived to be a major cause of absenteeism as well, followed once more by re s p i r a t o ry and GI p roblems. It is interesting to note that migraine headaches appear on this list as well. The medical literature has shown that a relatively small expenditure for migraine treatment can have a tremendous re t u rn on investment for the employer. 5 The relationship of indirect costs to direct costs can vary depending upon the chronic condition in question. In the early 1990s, re s e a rchers began comparing these relative costs for disease states and this pre l i m i n a ry data suggests indirect costs (i.e., lost productivity) are the primary cost factor for migraine headaches, arthritis, and depression ( Figure 1). 6 In recent times, the methods for measuring presenteeism have improved s u b s t a nt i a l l y, and the medical community is beginning to appre c i a t e j u s t how large the impact of depression is on this aspect of work p e rf o rmance. One can anticipate that this economic factor will only gain importance as additional re s e a rch is devoted to this t o p i c . Yet another area that re s e a rchers have only begun to unravel is the impact of pharmaceuticals upon pro d u c t i v i t y. As pre v i o u s l y mentioned, depression is widely recognized as a major cause of d i s a b i l i t y. The good news is that medications can have a very favorable-and measurable-effect on worker pro d u c t i v i t y. 7 I m p rovements seen with antidepressants actually appear to be much greater than with medical treatments used to manage a n x i e t y, migraine headaches, and hypertension ( Figure 2). 7 O n c e m o re, it is hoped that contemporary re s e a rch methods will be employed in the near future to improve our understanding of this i s s u e .

■■ Conclusion
D e p ression is a big cost factor for employers, but it also re p re s e n t s a big cost-saving opport u n i t y. In the developed world, depre s s i o n is viewed as a leading cause of disability, and its influence upon p resenteeism is particularly profound. With a combination of p h a rmacotherapy and psychotherapy, depression is eminently t reatable but oftentimes goes undiagnosed, untreated, or subopti-  Promoting Health and Productivity for Depressed Patients in the Workplace mally treated, and the associated costs become unnecessarily high. Integrated care models can result in substantial cost savings and a much more productive workforc e .

DISCLOSURES
The author received an honorarium for participation in the symposium upon which this article is based. He discloses no potential bias or conflict of intere s t relating to this art i c l e .